Assessing the design of China’s complex health system – Concerns on equity and efficiency

Following the global trend of moving towards Universal Health Coverage, China has implemented a new round of health system reform, to achieve universal “safe, effective and affordable basic healthcare services” by 2020. We review the latest reforms using the World Health Organization framework developed by Murray and Frenk. In particular, we diagrammatically describe the structure of the current Chinese health system using the dimensions of Stewardship, Resource Generation, Financing and Provision, and assess the variability of access, levels of benefits, and quality of service across populations. We identified several areas of inequity and inefficiency. First, the fragmented institutional arrangements, with distinct objectives and responsibilities across agencies, create potential nonalignment of incentives. Second, there is a marked scarcity of qualified general practitioners and infrastructures despite the continuing effort to improve the gatekeeping function of primary care providers. Third, as risks are pooled only at the local level within different insurance schemes, the considerable income heterogeneity across geographic territories and resident types can generate significant inequality in access and funding. Fourth, persistent patient preference for higher quality healthcare at hospitals prevents the integration of care across tiers. We believe our comprehensive analysis will be informative for both health policymakers and researchers, in identifying and investigating the inefficiencies of the health system and the potentials for structural integration to achieve healthcare equity.